A particular epidemiological profile: disparities in access to contraceptive methods in Brazil during the SARS-CoV-2 (COVID-19) pandemic

Our objective was to study disparities in access to contraception during the COVID-19 pandemic. We performed a cross-sectional study at the University of Campinas, Brazil using a Google questionnaire applied from December 2021 until February 2022, disseminated via snowball technique. The survey asked about sociodemographic characteristics and contraceptive use, as well as the demand for new methods and difficulties in continuing to use contraceptives during the COVID-19 pandemic. We analyzed 1018 completed questionnaires; in total, 742 (72.9%) were women aged between 20 and 39 years, 746 (73.3%) were White and 602 (59.2%) used contraceptives. During the COVID-19 pandemic, about 23% of respondents changed their method and approximately 20% of respondents looked for new methods. Among the latter, 31.3% reported some difficulty with obtaining guidance on new methods while only 5.3% of the respondents reported some difficulty with continuing their contraceptive. The main difficulty in both cases was the difficulty with getting a healthcare provider appointment. Our results point to a particular epidemiological population, of younger black and biracial women, with lower education and lower income, which suffered health disparities during the COVID-19 pandemic and found difficulties with using contraceptives and accessing family planning services.


Methods
We conducted a cross-sectional study using an online questionnaire developed by the family planning outpatient team of the Department of Obstetrics and Gynecology, University of Campinas Faculty of Medical Sciences, Brazil.The university of Campinas ethics committee approved the research protocol.Using Google Form (Google LLC, Mountain View, CA, USA), we designed an online, self-administered questionnaire, whose answers were not mandatory, applied from December 3, 2021, until February 8, 2022.A pilot version of the questionnaire was tested on 15 women, doctors and nurses at the family planning clinic to ensure its clarity and the time it would take to complete.
We invited self-identified women without any exclusion criteria via social media platforms (WhatsApp and Facebook, Instagram) to answer the questionnaire.We used the snowball technique to disseminate the study by asking women who were working at the family planning clinic, as well as using the family planning clinic´s social media profiles to disseminate the study, and we also asked the respondents to send the questionnaire to their women contacts on social media.
When accessing the online questionnaire and reading an introduction explaining its contents, an Informed Consent Form was provided; it was only possible to continue with the questionnaire after confirming adulthood and consent.After each participant completed the questionnaire, the form was directed automatically to an Excel sheet generated by Google.When analyzing the answers, we excluded post-menopausal women, pregnant women and hysterectomized women.The entire study was carried out followed the relevant Brazilian and international ethical guidelines and regulations.
The survey asked about sociodemographic characteristics, history of COVID-19 infection, disease or vaccination, current contraceptive use, the demand for new methods and difficulties with continuing to use contraceptives during the COVID-19 pandemic.They were also asked about their menstrual cycle during the pandemic, as well as infection and vaccination against COVID-19; this information was published elsewhere 24 .
We asked about the use of current contraceptives and whether it was difficult to keep using the method, as well as if it was difficult to get guidance on new methods, grading the answers from very easy to very difficult.If the answer was difficult or very difficult, they were asked why and could choose between the options: difficult to find the method, difficult to buy the method, I couldn't get a provider's appointment for advice, I can't renew my prescription, or other.The respondents were also asked if they had changed contraceptives and, if so, to which method.

Analysis
We first described our sample and the reported use of contraceptives.We then described any difficulties with continuing to use the method and, when there was difficulty, we described why.We described whether there had been any change in method and if so to which method.We also described whether there had been a change in method, whether there had been any difficulty with finding guidance on methods and if there had been difficulty, the main reasons.Finally, we explored potential relationship between the difficulties with maintaining contraceptive use and the demand for new methods with socio-economic variables, including age, ethnicity, years of schooling, occupation, family income, contraceptive use (yes or no) and type.
We performed descriptive analysis with frequency tables for categorical variables.The Chi-square test or Fisher's exact test were used to verify associations or compare proportions, when necessary.The level of significance adopted for the statistical tests was 5%.We used SAS version 9.4 (SAS Institute Inc, 2002-2008, Cary, NC, USA) software for all analyses.

Ethical approval
The university of Campinas ethics committee approved the research protocol.When accessing the online questionnaire and reading an introduction explaining its contents, an Informed Consent Form was provided; it was only possible to continue with the questionnaire after confirming adulthood and consent.The entire study was carried out followed the relevant Brazilian and international ethical guidelines and regulations.

Results
We received 1060 questionnaires, the answers for which were not compulsory; the data for missing answers are described in the tables.In total, 11 questionnaires were excluded because they were more than 30% incomplete, 17 were excluded because the respondents were pregnant and 14 were excluded because they were hysterectomized women, leaving a total of 1018 responses to be analyzed.Of these, 742 (72.9%) women were aged between 20 and 39 years, 746 were White (73.3%) and 602 (59.2%) were using contraceptives at the time of the questionnaire (Table 1).Only 5.3% of the respondents reported some difficulty with continuing contraceptive use, with most of the answers being equal difficulty or easy (Table 2).However, among those who found it difficult or very difficult, the main reason was not being able to get a healthcare provider's appointment or difficulties with paying for the method (Table 2).About 23% of respondents changed their method during the COVID-19 pandemic (Table 2) and approximately 20% of respondents looked for new methods during the COVID-19 pandemic (Table 3).Among the latter, 31.3% reported some difficulties with obtaining guidance on new methods during the pandemic (Table 3).The www.nature.com/scientificreports/main issue in this regard was the difficulty with getting a medical consultation (56.5%).The analysis of changing methods and seeking new methods during the pandemic according to current contraceptive use (yes/no) showed that most women who did not use methods did not seek them (87.8%) or did not change methods (85.7%), while Table 1.Sociodemographic, clinical and gynecologic characteristics of the questionnaire respondents, Brazil, (n = 1018).BMI, body mass index (kg/m 2 ); IUD, intrauterine device.*In Brazil, basic education consists of 12 full years of study.**In Brazil, the minimum recommended worker's income is defined as the "minimum wage" which is worth R$1320, equivalent to US$256.85.www.nature.com/scientificreports/28.5% of women who already used methods changed their method and 25.8% sought new ones (p < 0.0001 in both situations).The analysis between difficulty obtaining information about methods during the pandemic and the use of current contraceptives showed no significance.Analysis of the difficulty with continuing to use their existing method during the COVID-19 pandemic and variables shows a relationship with ethnicity, years of schooling, occupation and family income, with greater difficulty reported among black and biracial women, those with fewer years of schooling, unemployed women and those with lower incomes (Table 4).
Finally, the analysis between the demand for new methods during the COVID-19 pandemic shows a relationship with age, years of schooling, occupation, family income and current contraceptive method, with greater  www.nature.com/scientificreports/demand reported up to the age of 39 years, in those with fewer years of schooling and among students, registered workers and low-income individuals (Table 5).Most of the women who changed their method opted to use copper or hormonal intrauterine devices (IUDs), while most of the women who did not change their contraceptives during the pandemic either did not use any method or used the pill (Table 5).There was no statistical significance for the relationship between the ease of finding new methods and the demographic characteristics analyzed.

Discussion
Family planning is crucial for the sustainable development of all individuals, as it enables people to achieve their reproductive goals while also reducing problems arising from unplanned pregnancies and abortions, as well as reducing the risk of maternal and infant mortality [25][26][27] .The impact of COVID-19 pandemic on family planning services and access to contraceptives has been highlighted by the United Nations, especially among young women and adolescents and in low-and middle-income countries, and thinking about SRH policies for gender equity during this period is even more fundamental 28,29 .
In our study, approximately 45% of the women did not use a method or used behavioral awareness methods or condoms, which is indicative of an unmet need for modern contraceptives that is also found in other countries 9 .A high proportion of women were not in a stable relationship, which may have influenced the decision to use short-acting contraceptive methods (SHAC) or not to use a method at all 9,30 .
The use of SHAC, such as the pill or injectables, which are available in pharmacies over the counter in Brazil, is around 24%.A study carried out in Brazil showed that sales of injectables and pills during the COVID-19 pandemic increased in the first months of the pandemic, coinciding with the closure of many family planning clinics, with a subsequent increase in the sale of hormonal-IUD and implants in the private sector, indicating an inequity against the poorest individuals 31 .
We also observed that almost 30% of participants were using LARC methods, which shows a higher use than the common methods 9 .Furthermore, almost 50% of the women who changed their contraceptive method chose and were able to obtain LARC, which may show the resilience of family planning services during the pandemic in Brazil and the importance of keeping these services open to the population using the national health service.Regarding the demand for new methods, the majority did not change their method during the pandemic, with many who did not change their contraceptives being shown to not use a method or to be using the pill.This indicates that the pandemic did not lead to a change in the desire to become pregnant in the population studied.Despite this, approximately 20% sought new methods and changed their methods during the pandemic.Those who sought out new methods were mostly young women with 12 years or less of schooling, students and those with low incomes, which reinforces the gap in the unmet need for family planning 9,32 .
Despite representing approximately 5% of the sample, women who showed difficulties with maintaining contraceptive use during the pandemic have particular characteristics; the majority were black or biracial, with fewer years of schooling, were unemployed and had a low family income 3 .These inequities were also reported globally [33][34][35] .
Among the main reasons were difficulties with buying contraceptive methods, which may demonstrate the economic crisis faced during the pandemic by this part of the population 21,23 , especially according to recent national data showing that White people are paid 61.4% more than Black people (Black and biracial) per hour of work in Brazil 36 and difficulties with getting a medical consultation; this may demonstrate the barriers to access imposed on the poorest, least educated and Black and biracial people 17,37,38 .In addition, around 30% found it difficult to obtain new information about contraceptive methods, with the main reason being that they were unable to find a healthcare provider appointment.
Efforts need to be increased in this specific epidemiological group, which consists of black or biracial women with fewer years of schooling, who are unemployed and have a low income, in order to maximize the effects of family planning, access to information and maintaining the use of methods.In particular, racism can be a  17,37,39 .Racism in the use of health services is associated with more reports of negative experiences in the health service, delays or failure to obtain appointments and lack of adherence to the proposed treatment 37 .In Brazil, the chance of a Black or biracial person not being able to access health services is twice as high as for a White person 40 and it has long been a fact that black and biracial women with lower levels of education and family income use less contraception and have more children 41 .In the case of family planning, its impact may be in the delay in consultations or barriers by professionals to prescribing or inserting LARC methods.Despite the universal access that Brazil's public health system provides, efforts still need to be focused on black or biracial women with fewer years of schooling, who are unemployed and have a low income, tackling barriers such as racism and social inequality, as well as relying on human rights principles 32 .
The main strength of our study is that the online questionnaire allowed us to collect data quickly, anonymously and with wide national coverage.In addition, the questionnaire was administered during the COVID-19 pandemic, reducing recall bias.The main limitation was that the sample was obtained by convenience, which may have contributed to the selection of predominantly White women, with a high level of education and higher incomes.However, this information is still relevant, demonstrating the epidemiological profile of the population that has access to the internet and has time to respond to surveys.
Future studies should focus on techniques or conditions that make it easier for underserved populations to improve the access to both information and family planning consultations, as well as reducing barriers when it comes to prescribing a method or starting a LARC methods.In view of the above results, and the evidence worldwide about disparities in sexual and reproductive health, it would be essential during public health crisis that policy makers considered that family planning services are essential, so that their activities are not delayed or suspended.
In conclusion, our results point to a particular epidemiological population, which has suffered health disparities during the COVID-19 pandemic, in the difficulty of using and accessing family planning services.It is essential, especially during pandemics when the course of health is uncertain, to mitigate such disparities and their negative health consequences, focusing on public health actions that guarantee such rights to younger, black and biracial women, with lower education and lower incomes.

Table 2 .
Difficulty in using contraceptives and main barriers to access during the COVID-19 pandemic for the questionnaire respondents, Brazil, (n = 1018).Difficulty to keep up using this contraceptive method during the pandemic (n = 1011)

Table 3 .
Demand for new methods during the during the COVID-19 pandemic and main barriers to access of the questionnaire respondents, Brazil, (n = 1018).

Table 4 .
Difficulty in maintaining contraceptive use, stratified by age, ethnicity, years of schooling, occupation and family income, Brazil, (n = 596).*Based on Fisher's exact test/**based on Chi-square test.***In Brazil, basic education consists of 12 full years of study.****In Brazil, the minimum recommended worker's income is defined as the "minimum wage" which is worth R$1320, equivalent to US$256.85.

Table 5 .
Demand for new contraceptive methods during the COVID-19 pandemic, stratified by age, ethnicity, years of schooling, occupation, family income, and contraceptive method of the respondents, Brazil, (n = 995).*Based on Chi-square test/**based on Fisher's exact test.***In Brazil, basic education consists of 12 full years of study.****In Brazil, the minimum recommended worker's income is defined as the "minimum wage" which is worth R$1320, equivalent to US$256.85.